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Behavioral Health Care Management Program

Blue Cross and Blue Shield of Texas (BCBSTX) manages behavioral health services for all non-HMO members who have behavioral health benefits through BCBSTX. For HMO members, behavioral health and substance abuse services are delivered by Magellan Health Services’ provider network.

Behavioral health care management is integrated with our medical care management program, as part of Blue Care Connection® (BCC), to help members access their behavioral health benefits and to improve coordination of care between medical and behavioral health providers. This program will help BCBSTX clinical staff identify members who could benefit from co-management earlier, and may result in:

Improved outcomes

Enhanced continuity of care

Greater clinical efficiencies

Reduced costs over time

Some members* may be referred to other BCC medical care management programs that are designed to help identify and help close potential gaps in care through evidence-based and member-focused approaches to health care and benefit decisions.

All behavioral health benefits are subject to the terms and conditions as listed in the member's benefit plan.

* Members experiencing inpatient hospitalization, complex or special health care needs or who are at risk for medical complications may be referred to BCC programs through a variety of mechanisms such as predictive modeling, claim utilization, inbound calls, self-referrals and physician referrals. If members do not have BCC as part of their group health plans, they will not be referred to other BCC programs.

URAC, an independent, nonprofit organization, is well-known as a leader in promoting health care quality through its accreditation and certification programs. URAC offers a wide range of quality benchmarking programs and services that keep pace with the rapid changes in the health care system, and provide a symbol of excellence for organizations to validate their commitment to quality and accountability. Through its broad-based governance structure and an inclusive standards development process, URAC strives to ensure that all stakeholders are represented in establishing meaningful quality measures for the entire health care industry. For more information, visit www.urac.org.

The BCBSTX Behavioral Health Program encompasses a portfolio of resources that help BCBSTX members access benefits for behavioral health (mental health and substance abuse) conditions as part of an overall care management program. It also allows our clinical staff to assist in the early identification of members who could benefit from co-management of behavioral health and medical conditions.

Care Coordination Early Intervention (CCEI) Program provides outreach to higher risk members who often have complex psychosocial needs impacting their discharge plan.

Intensive Case Management provides intensive levels of intervention for members experiencing a high severity of symptoms.

Condition Case Management provides a comprehensive, integrated approach to the coordination of care for members with the following chronic mental health and substance abuse conditions:

Depression

Alcohol and Substance Abuse Disorders

Anxiety and Panic Disorders

Bipolar Disorders

Eating Disorders

Schizophrenia and other Psychotic Disorders

Attention Deficit and Hyperactivity Disorder (ADD/ADHD)

Patient Safety Program provides outreach calls to membersthat may have the potential of becoming higher risk for readmission(s) and/or frequent Emergency Room visits. The goal of the outreach is to provide resources and/or to ensure they have access to the treatment they need. Eating Disorder Specialty Team is a dedicated clinical team with expertise in the treatment of eating disorders. The team includes partnerships with eating disorder experts and treatment facilities as well as internal algorithms to identify and refer members to appropriate programs.

Autism Care Team whose focus is to provide expertise and support to families in planning the best course of Autism Spectrum Disorder (ASD) treatment for their family, including how to maximize their covered benefits.

Outpatient Management for members who have outpatient management as part of their behavioral health benefit plan through BCBSTX. The Behavioral Health Outpatient Program includes management of intensive and some routine outpatient services.

Referrals to other BCC medical care management programs, and wellness and prevention campaigns

Members are responsible for requesting preauthorization before treatment, when preauthorization is required. Behavioral health professionals and physicians or a member’s family member may request preauthorization on behalf of the member. All services must be medically necessary.

Inpatient and Alternative Levels of Care

Preauthorization is required for all inpatient, residential treatment and partial hospitalization admissions.

Elective or non-emergency hospital admissions must be preauthorized prior to admission or within two business days of an emergency admission.

Residential Treatment Center (RTC) benefits servicefor substance abuse (all ages) and mental health (up to age 18) are a standard benefit for BCBSTX Administrative Services Only (ASO) plans. To determine if RTC services are covered, call the appropriate number on the back of the member’s ID card.

Outpatient

These outpatient services require preauthorization prior to initiation of service:

Members are responsible for requesting preauthorization when preauthorization is required, although behavioral health professionals, physicians or member's family member may request preauthorization on behalf of the member. All services must be medically necessary.

Members who do not request preauthorization for inpatient and alternative levels of care behavioral health treatment may experience the same benefit reductions that apply to inpatient medical services. Medically unnecessary claims will not be reimbursed.

Outpatient

If a member receives any of the outpatient behavioral health services listed below without preauthorization, BCBSTX will request clinical information from the provider for a medical necessity review. The member will also receive notification.

Behavioral Health providers have contractually agreed to offer appointments to our members according to the following appointment access standards:

Routine: Within 10 working daysUrgent: Within 24 hoursNon-life threatening emergency:Within six (6) hoursLife threatening/emergency: Within one (1) hour

BCBSTX is accountable for performance on national measures, like the Health Effectiveness Data Information Sets (HEDIS). Several of these measures specify expected timeframes for appointments with a behavioral health professional.

Expectation that member has a follow up appointment with a behavioral health professional following a mental health inpatient admission within 7 and 30 days

Continuity and coordination of care are important elements of care and as such are monitored through the BCBSTX Quality Improvement (QI) Program. Opportunities for improvement are selected across the delivery system, including settings, transitions in care, patient safety, and coordination between medical and behavioral health care.

Communications and coordination of care among all professional providers participating in a member's health care are essential to facilitating quality and continuity of care. When the member has signed an authorization to disclose information to a primary care physician (PCP), the behavioral health provider should notify the PCP of the initiation and progress of behavioral health services.